Cardio-Oncology at the Point of Referral: Who Needs Baseline Imaging and Who Does Not
DOI:
https://doi.org/10.5281/zenodo.22344704Keywords:
Cardio-oncology, HFA-ICOS, Cardiotoxicity, Cancer therapy-related cardiac, Baseline risk assessmentAbstract
Guidelines answer the question of who needs baseline cardiac assessment before potentially cardiotoxic cancer therapy with a
specific tool: the HFA-ICOS risk stratification framework, which sorts patients into low, moderate, high, or very-high risk
categories and recommends escalating baseline echocardiography, biomarker testing, and cardiology referral accordingly.
The 2022 ESC Cardio-Oncology Guidelines endorse this approach with Class I recommendations, and a meta-analysis of
unselected breast cancer patients receiving anthracyclines found that routine baseline assessment has genuinely low yield --
only 2.5% of patients showed an abnormal baseline left ventricular ejection fraction, and only 1.6% had their chemotherapy
decision changed as a result -- supporting the case for a risk-stratified rather than universal approach. But a real-world
validation of the HFA-ICOS tool in 687 HER2-positive breast cancer patients found that the tool the guidelines rely on to
decide who is low risk and who is not barely distinguishes them in practice: composite cardiotoxicity occurred in 38.8% of
patients labelled low risk, 38.5% of those labelled moderate risk, and 41.4% of those labelled high risk -- a nearly flat curve,
with area-under-curve discrimination of only 0.51-0.55 across outcome definitions, barely better than chance. Only the
very-high-risk category, containing just 4 of the 687 patients, showed a clearly different event rate. This review sets out the
guideline framework for baseline risk stratification, the evidence supporting a selective rather than universal approach to
baseline imaging, and the complication those two positions run into when they meet: a risk tool that is genuinely useful for
excusing the truly low-yield majority from unnecessary testing is far less reliable, on current evidence, for confidently telling
any individual low-risk patient that their personal risk of cardiotoxicity is actually lower than a moderate- or high-risk
patient's.
dysfunction
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